Health
program for diabetic foot treatment
(Portuguese
PDF version)
Cícero
Fidelis Lopes*
*
Coordinator of Diabetic Foot Care, Center for Diabetes of the State
Department of Health of Bahia (CEDEBA).
Correspondence:
Dr. Cícero Fidelis Lopes
Rua Mons. Gaspar Sadock, 40/104
CEP: Jardim Armação - Salvador - Bahia
Tel.: +55 71 367.7388
J Vasc
Br 2003;2(1):79-87
INTRODUCTION
With the
improvement of the general approach to diabetes mellitus (DM) patients,
the survival rate increased and the complications can be detected more
frequently. Among these complications, foot lesions may lead to some
kind of lower limb amputation.
Despite all technological advances in medicine, rates of amputation
of lower extremities in DM patients have been high, which indicates
that we should reflect upon the subject and try to find alternative
solutions.
Current medical literature offers consistent data that allow making
an early diagnosis of the lesions that precede ulceration and amputation
and then taking the proper therapeutic and preventive measures.
Although the literature broadly mentions diagnostic methods, treatment
and prophylaxis of neuropathy, angiopathy and infection (some of which
are costly and somewhat complex), the aforementioned lesions, regarded
as risk factors, may also be identified by way of simpler evaluations,
in a consistent manner and at low costs, as proposed by the International
Consensus on Diabetic Foot held in Holland, in May 1999.
The foot lesion in DM patients results from the combination of two or
more risk factors. In most DM patients, peripheral neuropathy has a
pivotal role: over 50% of diabetic patients type II show neuropathy
and feet at risk.
Neuropathy leads to sensory loss (loss of protective sensation) and
subsequently to foot deformity, with possibly abnormal gait. Neuropathy
leaves the patient vulnerable to slight traumas (caused, for instance,
by inappropriate footwear or by skin lesions from walking barefoot),
which could predispose to ulceration.
Foot deformity and restricted joint motion may result in abnormal biomechanical
load to the feet, with formation of hyperkeratosis (callus), which culminates
in the loss of skin integrity (ulcer). The patient feels no pain and
keeps on walking, which prevents healing.
Peripheral vascular disease associated with slight traumas may result
in purely ischemic pain and ulcer. However, one should not forget that
patients with ischemia and neuropathy (neuroischemic ulcer) might show
no symptoms despite severe ischemia. Finally, some lesions might be
a source of infection, which could dramatically deteriorate the status
of DM patients.
Notably, the Practical guidelines on the management and prevention of
the diabetic foot, established in 1999, indicate that the aim set by
several countries and organizations, including the World Health Organization
and the International Diabetes Federation, is to achieve a 50% reduction
in amputation rates. We have to follow these guidelines; we should not
ignore the situation any longer.
Therefore, we believe that by developing a simple and low-cost program
for "foot care" may bring remarkable benefits to DM patients.
PROJECT
OBJECTIVES
General
aims
- To strengthen health measures for the identification and classification
of foot lesions in DM patients, in order to facilitate preventive and
therapeutic measures in a simpler way (that is, measures that health
professional can easily understand), but consistently and at a low cost.
Specific
aims
- To identify risk factors for ulceration and amputation of lower limbs
in DM patients by means of clinical examination (inspection and palpation)
and a sensory test;
- To classify/categorize individuals into different risk groups;
- To define the role/responsibility of primary, secondary and tertiary
care units;
- To allocate DM patients to the respective health units;
- To adopt previously defined preventive and treatment measures at each
health unit;
- To periodically reassess the program for possible improvements or
necessary adjustments.
JUSTIFICATION
AND STATISTICAL ASPECTS
Over 120
million people around the world suffer from DM and many of them have
foot ulcers that could lead to lower limb amputation, causing problems
to the patient and to the health system.
A study conducted by the Ministry of Health revealed a prevalence of
7.8% for diabetes in the 30-69 age group in the population of the State
of Bahia. The literature reveals a diagnostic rate of diabetes between
15% and 19% at surgical intervention.
In the United States and Sweden, respectively 50% and 32% of nontraumatic
lower limb amputations are performed in diabetic patients. There is
a 15-fold risk when compared to nondiabetic individuals.
The recent Brazilian Study about the Monitoring of Lower Limb Amputations
indicated that in Rio de Janeiro and in Baixada Fluminense the incidence
of lower limb amputations amounts to 180/100,000 diabetics, as against
13.8/100,000 inhabitants, which therefore represents a 13-fold risk
compared to nondiabetic individuals.
Ulcers precede 85% of lower limb amputations among diabetics, gangrene
corresponds to 50%-70% of the cases and infection represents 20%-50%.
Therefore, in most lower limb amputations, ischemia and infection are
combined.
It is estimated that 10% of diabetic patients will develop foot ulcers
in their lifetime. Approximately 80% to 90% of ulcers are precipitated
by external trauma (usually by inappropriate footwear). Between 70%
and 100% of lesions show clear signs of neuropathy, and only 10% of
ulcers are purely vascular. A large number of foot infections in diabetic
patients result from perforating traumas or from lesions between toes
and around nails.
Angiopathy (peripheral vascular disease) in diabetics has peculiar clinical
manifestations, like occurring earlier and being more common and more
diffuse. Diabetic patients with peripheral vascular disease are 17 times
more likely to develop gangrene than nondiabetic individuals. Microangiopathy
should not be accepted as the primary cause of an ulcer.
There is paucity of specific data in our setting, although the daily
work of health professionals involved show a remarkable frequency of
patients with foot disorders, especially in emergency situations and
in irreversible state.
We surveyed lower limb amputations between January 1st and July 30th,
1999 at three large public hospitals in Salvador and we obtained the
following results: Hospital Universitário Professor Edgar Santos
(HUPES) = 12, Hospital Geral do Estado (HGE) = 48 and Hospital Central
Roberto Santos (HCRS) = 204. At HUPES and at HGE approximately 50 %
of the cases presented diabetes; we could not assess these data at HCRS,
due to some problems with the Medical and Statistical File Service (SAME).
Most causes related to the indication of amputations included ischemia
and infection, which is consistent with international literature.
In a survey at the emergency unit of HCRS (State Department of Health
of Bahia - SESAB), carried out between April 3rd and May 3rd 2000, 27
patients revealed foot lesions, of whom 23 were diabetic. We found out
that the origin of foot lesion was associated with trauma in 20 patients,
50% of which were caused by single trauma and 50% by repeated trauma;
16 and 11 patients showed ischemia and infection, respectively, which
is also consistent with the international literature.
In our setting, data on costs are scarce; however, the literature reveals
that foot complications are one of the most costly and serious complications
of DM.
Daily experience shows that diabetic foot is associated with relevant
rates of hospitalization and hospital stay, with repeated surgical interventions,
repeated hospitalizations during the same year which, unfortunately,
lead to some type of lower limb amputation, causing problems to patients,
family, and health organizations. Nevertheless, several scientific studies
indicate that there are risk situations that may be treated, controlled
or prevented before lower limb amputation.
Given this scenario, we believe the problem should be broadly discussed
and a program for the treatment and care of diabetic foot should be
devised, with an essentially educational purpose at the beginning.
The International Consensus on Diabetic Foot, of May 1999, states that
"a program for diabetic foot, including education, regular examination
of the foot, and risk classification, may reduce the incidence of foot
lesions by over 50%." The Consensus also affirms that "a strategy
that includes prevention, education of patients and health professionals,
multidisciplinary treatment of foot ulcers and close monitoring may
reduce the amputation rate of lower limbs by 49 to 85 %."
The Practical guidelines on the management and the prevention of the
diabetic foot, of 1999, suggest adapting all recommendations to the
socioeconomic and cultural situation of the target population and recommend
a multidisciplinary approach.
OPERATIONAL
STRATEGY
The
rationale behind the strategy
The Practical guidelines on the management and the prevention of the
diabetic foot present five cornerstones for the treatment of diabetic
foot: (1) regular inspection and examination of the foot at risk; (2)
identification of the foot at risk; (3) education of patient, family
and healthcare providers; (4) appropriate footwear; (5) treatment of
non-ulcerative pathology. In our setting, some limitations on items
4 and 5 are often found, but the first three items are enough for implementation
of the program.
By analyzing these recommendations, other literature sources and the
experience with the situation in the state of Bahia, a team from the
Center for Diabetes of the State Department of Health of Bahia designed
a project for management of diabetic foot, which is briefly outlined
below.
The
merit of the strategy
Preliminary
stage:
- Sensitization and consciousness-raising of healthcare providers in
the primary, secondary and tertiary health systems.
Stage
I:
- To qualify the multidisciplinary team of basic health units;
- To develop a referral and counter-referral system between the primary
and secondary health systems, keeping the tertiary health system exclusively
for more complex cases;
- To design educational material (posters, booklets, etc.) on diabetic
foot, thus reinforcing the actions developed in the basic health system;
- To provide technical support for the implementation and development
of actions related to diabetic foot care as part of a project for the
management of diabetic foot.
This stage is specifically targeted at primary health care and is characterized
by:
Identification of diabetic individuals;
Examination and classification of the foot at risk;
Education of patient, family and healthcare providers.
Organization
of measures
1) Primary (basic) health system
Sensitization and qualification strategy
General sensitization;
Theoretical and practical course;
Distribution of educational material;
Incorporation of nurses to supervise health agents;
Qualification of health agents by the team at heath units.
Preferential
inclusion criteria
Professionals previously qualified in DM and properly engaged in the
actions;
Basic health units with previously implemented DM measures;
Coordinators of health districts and health unit managers properly involved
and committed;
Installed physical capacity - health center;
Involvement of the Community Health Agent Program (PACS);
Capacity of distribution of educational material.
Strategy
for the monitoring of health units
Periodical visits to the respective units;
Presentation of monthly care reports;
Training at the diabetic foot outpatient clinic of the reference center;
Implemented educational activities (patients/family/health agents);
Involvement of project participants in scientific updating on DM.
Material
resources
Warranty of educational material for patient and family;
Warranty of educational material for health units.
Assessment
of piloted units (if applicable)
Evaluation seminar
2) Secondary
health system
Establishment of the role of outpatient clinics that treat diabetic
foot.
3) Tertiary health system
Establishment of the role of the hospitals that perform important procedures
for the project (e.g.: drainage, debridements, amputation, arteriography/revascularization),
both in emergency or elective situations, with special regard to the
relationship between these procedures and the reference center.
Stage
II (Simultaneous or sequential execution):
Targeted at the secondary and tertiary health systems with the aim of
defining the treatment/prevention of non-ulcerative and ulcerative pathologies
according to the possibility of resolution.
This approach includes surgical procedures such as drainage, debridements,
amputations and revascularizations. It also includes special footwear
and, whenever possible, elective or non-elective osteoarticular surgeries.
Monitoring
After examination and risk classification, all patients should be included
in scheduled reassessments according to their respective risk. Figure
1 shows all the steps involved in the project.
 Figure
1 - Algorithm for project management.
FINAL
REMARKS
We are
aware of how complex it is to provide total foot care to DM patients,
but we know that we can work with what is available, in a simplified
way, but consistently, in an attempt to directly or indirectly sensitize
all those involved and reduce the rates of amputation of lower limbs
in our setting.
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